Thursday, March 17, 2016

Democratic presidential candidate Hillary Clinton's ideas for improving
the Affordable Care Act (ACA) drew cautious praise from health policy
scholars, but they said they had no chance of enactment without a major
change in Congressional attitudes.

"If we're really serious about getting to the general uninsured and
getting costs down, and it's a choice between scratching everything and
starting over [or] building on the Affordable Care Act ... I would build
on what Clinton's talking about," Ken Thorpe, PhD, of Emory University
in Atlanta, said in a phone interview.

Clinton's plan is "Very much a small adjustment to ACA, and in the
climate we have, getting anything through [Congress] is a real
challenge," said Paul Hughes-Cromwick, MA, of the Center for Sustainable
Health Spending at the Altarum Institute, in Ann Arbor, Mich. "Most of
what she's talking about is very small, and some things are already
happening."

On her website, Clinton lists the following planks among those in her
healthcare proposal:

* Make premiums more affordable and lessen out-of-pocket expenses for
consumers purchasing health insurance on the ACA exchanges. This would
include a tax credit of up to $5,000 per family to offset a portion of
out-of-pocket and premium costs above 5% of income.

* Support new incentives to encourage all states to expand Medicaid.
Clinton proposes allowing any state that signs up for the Medicaid
expansion to receive a 100% match for the first 3 years.

* Invest in navigators, advertising, and other outreach activities to
make exchange enrollment easier. Today, as many as 16 million people or
half of all those uninsured are eligible but not enrolled in Medicaid or
an exchange plan. Clinton plans to invest $500 million per year in an
aggressive enrollment campaign.

* Expand access to affordable healthcare to families regardless of
immigration status. Clinton "believes we should let families --
regardless of immigration status -- buy into the Affordable Care Act
exchanges," according to her website.

* Continue to support a "public option." Clinton wants states to be
able to establish a public option under which people could buy into a
publicly funded health insurance plan.

* Defend the ACA. "Hillary will continue to defend the ACA against
Republican efforts to repeal it," the website said. "She'll build on it
to expand affordable coverage, slow the growth of overall health care
costs (including prescription drugs), and make it possible for providers
to deliver the very best care to patients."

* Lower out-of-pocket costs like co-pays and deductibles. "Hillary
believes that workers should share in slower growth of national
healthcare spending through lower costs," according to the website.

* Transform our healthcare system to reward value and quality. "Hillary
is committed to building on delivery system reforms in the Affordable
Care Act that improve value and quality care for Americans."

Compared with the plan offered by Clinton's Democratic primary opponent,
Sen. Bernie Sanders (I-Vt.), who wants to institute a single-payer
"Medicare-for-all" program, hers is "definitely more realistic," said
Michael Sparer, PhD, JD, of Columbia University in New York City, in an
interview. However, "a lot depends on what happens to Congress as well
[if she becomes President]. If something would change in Congressional
makeup, I think she has a pretty clear fix-it agenda."

Even without such a change in Congress, "she will try to use whatever
authority under ACA to encourage states to experiment," he added.

Similarly, Elbert Huang, MD, MPH, at the University of Chicago, said he
was impressed by the level of specificity in Clinton's plan, especially
compared with those of Sanders and Republican presidential candidate
Donald Trump.

Jon Oberlander, PhD, of the University of North Carolina-Chapel Hill,
agreed in an email that, overall, Clinton's plan is "more than
realistic" -- "if we are to continue to make progress in reducing the
uninsured population, making Obamacare more affordable for Americans
with modest incomes is imperative. Politically, however, even these
incremental measures are not so easy."

However, Oberlander continued, "As for [Clinton's] public option ... its
chances of enactment in the current Congressional environment are zero.
Even if Democrats retake majorities in Congress in 2016, it would face
an uphill path to enactment."

A federally run public option, he said, "is symbolic politics, something
that liberal Democrats like that allows Clinton to counter Sanders'
single-payer proposal."

Clinton's Medicaid expansion proposal "will be incredibly tricky to pull
off politically," said David Becker, PhD, of the University of Alabama
at Birmingham School of Public Health, in an email to MedPage Today.

"Even in a state like Louisiana where Medicaid expansion will take
effect on July 1, it is somewhat unlikely that Republican senators and
representatives would support expanding federal support. This proposal
also assumes that states that have already expanded their programs will
be happy to support the extension of funding without asking for
something in return."

As to spending more money on navigators, "I'm not entirely sure this is
money well spent," Becker said. "People that are eligible but not
enrolled for public health insurance programs tend to be low-utilizers
who re-enroll when they need care. Although marketing and outreach
efforts have varied across the states, the benefits of increased
spending on these efforts are not clear."

Clinton's proposal to lower out-of-pocket costs might work with plans on
the insurance exchanges, said Alan Sager, PhD, at Boston University, but
is incompatible with the economics of private insurance.

"For private employers it's very tough today, since employers and their
benefits advisors think that higher out-of-pocket costs are the one tool
they can wield to contain their healthcare costs," Sager said in an
email. "Many economists fantasize that higher out-of-pocket costs will
somehow shoehorn size 10 healthcare into size 5 free-market competition.
And some reporters and 'consumer advocates' fantasize that better
information about price and quality will make us healthcare super-shoppers."

Sager added, "Without real cost controls -- not widely supported
politically by Americans -- out-of-pocket costs will continue to look to
many people like the only game in town" for restraining overall costs.

He also dismissed the "reward value and quality" part of Clinton's plan,
calling it "tough to do without torturing hospitals and doctors to make
them give us still more data. And they control the data so they can game
the measures of value/quality if they want."

David Howard, PhD, another Emory University scholar, told MedPage Today
that he was troubled by Clinton's proposing of new spending without
suggesting how the costs would be offset.

"Clinton promises new subsidies for people who buy insurance on the
exchanges, new subsidies to help offset out-of-pocket costs, and
additional funds to subsidize state Medicaid expansions," he wrote in an
email. "At a time when the federal government is struggling to afford
entitlements, it is irresponsible to promise new spending without
offsetting spending reductions elsewhere."

Jan Carney, MD, MPH, at the University of Vermont in Burlington, said
she is concerned about what's missing from all the candidates'
proposals, including Clinton's.

"Public health issues such as infant mortality, obesity, HIV, injuries,
homicides, and drug-related deaths all represent preventable
contributors to health care costs," she said in an email. "These
specific areas (where we do much worse than other countries) and other
areas of public health, would make a strong addition to this national
healthcare discussion."

Christopher Jones, PhD, of the Vermont Center for Clinical and
Translational Science, in Burlington, named another topic of concern:
biocybersecurity. "Health information has a longer shelf life than
financial information and when both are sold on the black market, it is
health information that commands a higher price," he said in an email.
"This will most assuredly be a concern for the Democratic candidate when
s/he gets elected."

Not a very exciting article. And that's the point. When you read Hillary
Clinton's proposals, they all fall under the category of mere tweaks to
our current dysfunctional system.

Tens of millions will remain uninsured; underinsurance will not be
eliminated; Medicaid would be expanded without addressing its
deficiencies in access; administrative excesses, including waste in
marketing would increase; the undocumented would be allowed in without a
way to pay for it; an ineffectual public option would continue to be
offered through Section 1332 waivers; and so forth. Lower co-pays and
deductibles along with a higher tax credit would be helpful, but to be
effective, it would require significantly higher taxes when we have a
Congress that continues to resist, on a bipartisan basis, any tax increases.

Although the title of this article indicates that the health policy
experts cited give her efforts a "passing grade," they basically do not
see much more than fine tuning of the status quo. There is no suggestion
that we could achieve reform goals of universality, affordability,
increased provider choice, greater access, greater administrative
efficiency, and optimal equity in the financing of health care.

Many of the Clinton measures proposed would further increase health care
spending while falling short on goals. That would be a shame when
instead we could place effective controls on spending through a single
payer national health program - an improved Medicare for all - while
achieving all of the listed goals of reform.

/Physicians for a National Health Program (PNHP) is a nonpartisan
educational organization. It neither supports nor opposes any candidates
for public office./